Red Book Online Presents: Diagnosis Detective | November 2023
Editor: Kristina A. Bryant, MD, FAAP
Case contributed by Matthew M. Sattler, MD, Pediatric Infectious Diseases, St. Louis Children’s Hospital
A 6-week-old female infant is evaluated in the emergency department for a one-day history of decreased oral intake. She typically takes 5 ounces of prepared powdered infant formula per feed but in the past day has only wanted to take 1 ounce per feed.
Her past medical history is notable for premature birth at 33 weeks. She was discharged at 4 weeks of life on room air and tolerating full enteral feeds.
In the emergency room, her physical examination is notable for a bulging anterior fontanelle, axial hypotonia, and hypertonia of the upper and lower extremities. Her initial laboratory evaluation is notable for a hemoglobin of 9.0 g/dL (ref range 9.0-14.0 g/dL) and an elevated C-reactive protein of 190.0 mg/L (ref range <10 mg/L). Cerebrospinal fluid (CSF) analysis demonstrates a nucleated cell count of 2,200 (ref range 0-5 cells/cumm) (70% neutrophils, 12% bands) Gram negative bacilli are identified on Gram stain for CSF. A meningoencephalitis PCR panel is negative for Escherichia coli, Haemophilus influenzae and Neisseria meningitidis.
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